CT-guided transcutaneous drainage of peritonsillar abscess after failed ultrasound-guided drainage: A case report.

Peritonsillar abscess (PTA) is the most common deep neck infection in the United States. Timely treatment of PTA with antibiotics and aspiration or drainage is paramount, as delay in management may lead to further complications. The oral approach is the preferred route of drainage however may not always be accessible, warranting consideration of other routes of drainage. To the best of our knowledge, CT guidance for aspiration or drainage of a PTA has not been previously described. We present a 50-year-old patient with a PTA who initially presented with throat pain and dysphagia, rapidly developed upper airway obstruction, and required intubation. After the failure of clinical improvement and unsuccessful PTA aspiration via the conventional oral route, successful CT-guided percutaneous needle aspiration was performed by neuroradiology. Shortly thereafter, the patient clinically improved and was discharged with an oral course of antibiotics and follow-up on an as-needed basis. Total hospital length of stay was seven days. The complex patient may not allow for simple incision and drainage or needle aspiration of a suspected PTA. Assistance with ultrasound guidance is often utilized, however, challenges may persist depending on the anatomical location of the PTA and patient comorbidities. In cases where external drainage is considered and conventional ultrasound imaging is particularly challenging, CT-guided percutaneous aspiration may provide a useful alternative. PTAs are common with the possibility of complication. Although the usual route of drainage is oral, there are instances in which this cannot be performed. This case exhibits an uncommon approach to PTA aspiration via an external CT-guided percutaneous approach with rapid subsequent clinical improvement, exhibiting the utility of CT guidance.

Perceptual adaptation to gender and expressive properties in speech: the role of fundamental frequency.

Recent studies have demonstrated perceptual adaptation to nonlinguistic properties of speech involving voice gender and emotional expression. The present study extends this work by examining the contribution of fundamental frequency (F0) to these effects. Voice recordings of vowel-consonant-vowel (VCV) syllables from six talkers were processed using the STRAIGHT vocoder and an auditory morphing technique to synthesize gender (experiment 1) and expressive (experiment 2) speech sound continua ranging from one category endpoint to the other (female to male; angry to happy). Continuum endpoints served as adaptors for F0 present and F0 removed conditions. F0 removed stimuli were created by replacing the periodic excitation source with broadband noise. Confirming previous findings, aftereffects were found in the F0 present condition, resulting in a decreased likelihood to identify test stimuli as belonging to the adaptor category. No aftereffects appeared when F0 was removed, highlighting the importance of F0 in adaptation. However, in an identification test listeners were still able to categorize F0 removed stimuli at better-than-chance levels, indicating that residual cues for gender and emotion were available even when F0 was not present.

Meta-analysis of blood cortisol levels in individuals with first-episode psychosis.

OBJECTIVE: Schizophrenia is associated with abnormal neuroimmunoendocrine function. There is evidence for hypothalamic-pituitary-adrenal (HPA) axis abnormalities in individuals with first-episode psychosis (FEP). However, some previous meta-analyses have focused on heterogeneous sample sources and patient populations. We performed a meta-analysis of baseline (i.e., one sample) blood cortisol levels in individuals with FEP and minimal exposure to antipsychotics. METHOD: Articles were identified by searching PubMed, PsycInfo, Web of Science, and Science Direct, and the reference lists of these studies. RESULTS: Twenty-six studies (comprising twenty-seven samples) met the inclusion criteria. Blood cortisol levels were significantly increased in individuals with FEP compared to controls with a small-to-medium effect size (standard mean difference [SMD] = 0.37, 95% CI 0.16-0.57, p < 0.001). In meta-regression analyses, geography was a significant moderator of this association, with larger effects seen in studies conducted in Asia versus the Middle East. CONCLUSION: We found elevated blood cortisol levels in individuals with FEP, providing additional, complementary evidence for abnormal HPA axis function in this disorder. This finding, which does not inform on mechanism, is consistent with the "neural diathesis-stress" model of psychosis. Given the immunomodulatory effects of cortisol, methodologically rigorous longitudinal studies of cortisol parameters, inflammatory markers, and psychopathology in this patient population are warranted.

Advances in Molecular biomarker for early diagnosis of Osteoarthritis.

Osteoarthritis (OA) is a chronic degenerative joint disease. The pathogenesis is poorly understood. What is known is that OA is characterized by imbalance in anabolic and catabolic gene expression in articular chondrocytes. This results in bone on bone articulations resulting in impaired mobility and joint pain. Although the cause of OA is unknown, comorbidities include: aging, obesity, and mechanical stress. Currently the only diagnostic modalities are radiology and physical examination, and early detection is rare. Biomarkers are quantifiable substances, and their presence can be suggestive of a certain phenomenon or disease. Biomarkers are popular for early diagnosis for pathological conditions in the fields of oncology, cardiology, and endocrinology. This review has systematically reviewed the literature about biomarkers in the field of OA, specifically protein, miRNA, and metabolic biomarkers found in the blood, urine, and synovial fluid.

Pyogenic Flexor Tenosynovitis by Point-of-care Ultrasound in the Emergency Department.

INTRODUCTION: Pyogenic flexor tenosynovitis (PFT) is difficult to diagnose on clinical grounds alone as many patients requiring an operation do not have all four of Kanavel's signs. Previous studies have shown that hypoechoic fluid surrounding the flexor tendon on ultrasound is associated with this diagnosis. We sought to determine if emergency physicians (EPs) could recognize this finding in patients with suspected flexor tenosynovitis using point-of-care ultrasound (POCUS). METHODS: We present a retrospective case series of seven patients suspected of PFT who had hypoechoic fluid surrounding the tendon on POCUS performed by the treating EP. We report on the patient characteristics, history of trauma by puncture wound, number of Kanavel's signs, treatment course, and operative findings. RESULTS: We identified seven patients suspected to have flexor tenosynovitis by the emergency department attending physician who had anechoic or hypoechoic fluid surrounding the flexor tendon on real-time POCUS examination. Patients ranged in age from 16 - 51 years. All were male. All patients had at least two of Kanavel's signs on examination. Five of seven (71%) patients had history of recent trauma to the affected hand. Four of seven (57%) were managed in the operating room. One of seven (14%) had incision and drainage at the bedside, and the remaining two (28%) were managed non-operatively and successfully with antibiotics alone. CONCLUSION: Our study demonstrates that EPs can recognize the finding of hypoechoic or anechoic fluid surrounding the flexor tendon on POCUS.

Pros and cons of mouse models for studying osteoarthritis.

Osteoarthritis (OA) is one of the most common chronic conditions in the world today. It results in breakdown of cartilage in joints and causes the patient to experience intense pain and even disability. The pathophysiology of OA is not fully understood; therefore, there is currently no cure for OA. Many researchers are investigating the pathophysiology of the disease and attempting to develop methods to alleviate the symptoms or cure the OA entirely using animal models. Most studies on OA use animal models; this is necessary as the disease develops very slowly in humans and presents differently in each patient. This makes it difficult to effectively study the progression of osteoarthritis. Animal models can be spontaneous, in which OA naturally occurs in the animal. Genetic modifications can be used to make the mice more susceptible to developing OA. Osteoarthritis can also be induced via surgery, chemical injections, or non-invasive trauma. This review aims to describe animal models of inducing osteoarthritis with a focus on the models used on mice and their advantages and disadvantages that each model presents.

Production and perception of emotional prosody by adults with autism spectrum disorder.

This study examined production and perception of affective prosody by adults with autism spectrum disorder (ASD). Previous research has reported increased pitch variability in talkers with ASD compared to typically developing (TD) controls in grammatical speaking tasks (e.g., comparing interrogative vs. declarative sentences), but it is unclear whether this pattern extends to emotional speech. In this study, speech recordings in five emotion contexts (angry, happy, interested, sad, and neutral) were obtained from 15 adult males with ASD and 15 controls (Experiment 1), and were later presented to 52 listeners (22 with ASD) who were asked to identify the emotion expressed and rate the level of naturalness of the emotion in each recording (Experiment 2). Compared to the TD group, talkers with ASD produced phrases with greater intensity, longer durations, and increased pitch range for all emotions except neutral, suggesting that their greater pitch variability was specific to emotional contexts. When asked to identify emotion from speech, both groups of listeners were more accurate at identifying the emotion context from speech produced by ASD speakers compared to TD speakers, but rated ASD emotional speech as sounding less natural. Collectively, these results reveal differences in emotional speech production in talkers with ASD that provide an acoustic basis for reported perceptions of oddness in the speech presentation of adults with ASD. Autism Res 2017, 10: 1991-2001. © 2017 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: This study examined emotional speech communication produced and perceived by adults with autism spectrum disorder (ASD) and typically-developing (TD) controls. Compared to the TD group, talkers with ASD produced emotional phrases that were louder, longer, and more variable in pitch. Both ASD and TD listeners were more accurate at identifying emotion in speech produced by ASD speakers compared to TD speakers, but rated ASD emotional speech as sounding less natural.

Randomized clinical trial of nebulized fentanyl citrate versus i.v. fentanyl citrate in children presenting to the emergency department with acute pain.

OBJECTIVES: To compare the pain relief achieved with nebulized fentanyl citrate with intravenous (i.v.) fentanyl citrate in children presenting to the emergency department (ED) with painful conditions to determine if nebulized fentanyl is a feasible alternative to i.v. fentanyl for the treatment of acute pain in children. METHODS: This was a randomized controlled trial in an urban county medical center ED with an annual census of 99,000 visits. ED patients, aged 6 months to 17 years, presenting with acute pain who were going to be treated with i.v. pain medications, were eligible for enrollment. After the parents had provided informed consent, and children older than 6 years had provided assent, patients were randomized (1:2) to receive either fentanyl citrate i.v. (1.5 microg/kg) or fentanyl citrate by breath-actuated nebulizer (3.0 microg/kg). Patients aged 6 years and older completed a 100-mm visual analog scale (VAS) describing their pain, and patients younger than 6 years had their pain assessed by the treating physician using the Children's Hospital of Eastern Ontario Pain Scale. Additionally, treating physicians used a 100-mm VAS to describe their perception of the patients' pain. These pain measurements were taken before treatment and every 10 minutes thereafter for 30 minutes. Baseline blood pressure, heart rate, and oxygen saturation were also measured before treatment and every 10 minutes for 30 minutes. After 30 minutes, physicians were asked whether or not they believed the medication provided adequate pain relief for the patient. Parents were asked to rate their satisfaction with the treatment using a five-point scale. Patients who received additional pain medications by any method before the 30-minute measurement period was completed were considered treatment failures. Data were compared using descriptive statistics and 95% confidence intervals; the rates of adequate pain relief between the groups were compared using Fisher exact tests. RESULTS: Forty-one patients were enrolled in the study; 14 were randomized to i.v. fentanyl (ten actually received it), and 27 patients were randomized to nebulized fentanyl (31 actually received it). In the four patients who were randomized to i.v. fentanyl but received nebulized fentanyl, the parents requested the nebulized medication after being told their child had been randomized to i.v. fentanyl. Baseline pain VAS scores were 82.8 mm (SD +/-14.3, 69-100) in the i.v. group and 76.2 mm (SD +/-20.5, 34-100) in the nebulized group. There were five treatment failures: one who received i.v. fentanyl and four who received nebulized fentanyl. The four patients who were considered treatment failures in the nebulized fentanyl group were all younger than 3 years and had difficulty triggering the breath-actuated nebulizer. The mean decrease in pain for patients remaining in the study was 55.1 mm (95% CI = 40.3 to 70.0) for the i.v. group and 77.8 mm (95% CI = 67.4 to 88.4) for the nebulized group. The pain treatment was described as adequate by the treating physician in eight of 14 patients in the i.v. group and 20 of 27 patients in the nebulized group (p = 0.42). No adverse events were detected. CONCLUSIONS: Nebulized fentanyl citrate 3 microg/kg through a breath-actuated nebulizer appears to be a feasible alternative to i.v. fentanyl citrate for a variety of painful conditions in patients older than 3 years.

Patient and physician perceptions as risk factors for oligoanalgesia: a prospective observational study of the relief of pain in the emergency department.

OBJECTIVES: Previous studies have reported that pain is undertreated in the emergency department (ED), but few physician-dependent risk factors have been identified. In this study, the authors determine whether pain treatment and relief in ED patients are negatively associated with the physician's perception of whether the patient was exaggerating symptoms, and with the patient and physician's perceptions of the interaction between them, as well as whether demographic characteristics were associated with these perceptions. METHODS: This was a prospective observational study of patients who were undergoing treatment for painful disorders in the ED. Before treatment for pain, patients were asked to complete a 100-mm visual analog scale (VAS) describing their pain. Demographic information and pain treatments administered were recorded. Patients completed a second pain VAS before discharge from the ED. Patients were then asked to complete three queries describing their perception of their interaction with the physician. After the patient had left the department, the patient's physician was asked to complete a query describing his or her perception of the interaction and to complete a VAS describing how likely it was that the patient was exaggerating symptoms to obtain pain medicines for nonmedical purposes. RESULTS: There were 1,695 patients enrolled in the study; 32 patients were excluded because of missing or incomplete data, leaving 1,663 for analysis. Of these patients, 71.9% received a pain medication while in the ED. There was no association between the physician's VAS for perceived exaggeration of symptoms, the queries describing physician-patient interactions, and patient ethnicity and whether patients received pain treatment in the ED. There was a negative correlation between the physician's VAS for perceived exaggeration of symptoms and the change in the patient's pre- and posttreatment pain VAS scores. The physician's VAS score for perceived exaggeration of symptoms was higher among Native American patients than among other ethnic groups (p < or = 0.001). The patient and physician queries rating their interaction show a decreased absolute reduction of VAS pain scores (p > or = 0.001) and a reduction in the number of patients having at least a 50% reduction in their pain VAS score when interactions were rated "bad" and "very bad" (p < or = 0.001). CONCLUSIONS: The physician's perception of whether a patient was exaggerating symptoms was associated with the patient's ethnic background and with both the physician's and patient's perception of their interaction. These perceptions were negatively associated with the achievement of pain relief and the change in the patient's pain VAS scores, but not with whether a patient was treated with a pain medication.